Understanding Moral Habitability: A Framework to Enhance the Quality of the Clinical Environment as a Workplace

Article excerpt

The clinical workplace is demanding and at times a damaging work environment (Cline, Reilly, & Moore, 2003; Jackson, Firtko, & Edenborough, 2007). Nurses experience adversity through organisational constraints, reduction in staffratios, escalating workloads, and where patient acuity is increasing (Jackson et al., 2007). This has an effect on the quality of patient care (Edward & Hercelinskyj, 2007) which can be further eroded by challenges such as abuse from patients and bullying from colleagues (Vessey, DeMarco, Gaffney, & Budin, 2009). In response to workplace adversity an emergent body of nursing ethics research focuses on links between the burden of difficult workplace environments and moral complexities of the everyday practice of nurses (Rodney et al., 2002; Storch et al., 2009b). These environments can be detrimental for both nurses and patients with research findings suggesting workplace adversity can lead to an exacerbation of moral distress (Austin, 2012; Pauly, Varcoe, Storch, & Newton, 2009), burnout (Edward & Hercelinskyj, 2007), increased staffturnover (Strachota, Normandin, O'Brien, Clary, & Krukow, 2003) and poor patient care (Cavaliere, Daly, Dowling, & Montgomery, 2010). In a large Canadian study researchers concluded that the adversity nurses experience in their workplaces made some environments ' morally uninhabitable' (Peter, Macfarlane, & O'Brien-Pallas, 2004).

While understanding the moral dimensions of the workplace is intuitively important, simply declaring an environment 'uninhabitable' is problematic. Some nurses will have no choice but to inhabit these environments and either suffer adverse effects, or adapt through inhibiting their capacity to provide morally sensitive patient care (Peter et al., 2004). Alternatively, they may leave the workplace environment all together (Ulrich et al., 2007).

Conversely, enhancing or sustaining an environment's habitability is important because habitable environments may affect the shaping of the moral identity of participants (Hardingham, 2004; Laabs, 2011). Nurses' moral actions and moral identity influence care choices. It is also important to focus on the habitability of the environment as it may influence the ability to maintain a consistent workforce. Despite the evidence that many nurses experience the workplace as morally uninhabitable, this concept remains underdeveloped.

CONCEPTUALISING MORAL HABITABILITY

The term 'moral habitability' was first used in the nursing literature in a study by Peter et al. (2004) that described a large study examining the impact of Canadian working environments on nurses. Though the original study was not conducted with a moral lens, the researchers found the data and implications were significantly moral in nature. A secondary analysis drawing on the work of Margaret Urban Walker (1998), a feminist ethical theorist, was conducted.

Walker locates moral epistemology in human social life and believes that morality exists in practices of responsibility which implement commonly shared understandings about which role is accountable for which task (Peter & Liaschenko, 2003). In this view morality is not socially modular - not a dimension somehow separate from other shared features of everyday life. In a healthcare environment under pressure, this construct is important as problems can be identified as practical rather than moral. Peter et al. (2004) suggest that using this theoretical perspective makes it imperative that moral-social orders in the work environment are made overt and scrutinised for moral habitability. The authors define moral habitability as:

those [environments] in which differently situated people experience their responsibilities as intelligible and coherent. They also foster recognition, cooperation and shared benefits. (p. 358)

The relational nature of the moral-social workplace influenced by Walker has, in the last decade, been reflected in the literature through opinion papers purporting the notion of a 'moral community' where mechanisms are instigated to enhance interaction between members of the community to influence better moral practice (Austin, 2007; Hardingham, 2004). …